Dinah, ClinkShrink, & Roy produce Shrink Rap: a blog by Psychiatrists for Psychiatrists. A place to talk; no one has to listen.
All patient vignettes are confabulated; the psychiatrists, however, are mostly real.
--Topics include psychotherapy, humor, depression, bipolar, anxiety, schizophrenia, medications, ethics, psychopharmacology, forensic and correctional psychiatry, psychology, mental health, chocolate, and emotional support ducks. Don't ask. (It's not Shrink Wrap.)

Tuesday, July 24, 2007

Did someone ask if we'd seen State of Mind, the latest greatest shrink show on Lifetime TV?So Annie is a psychiatrist, she's married to Eric who is also a psychiatrist, and they work together with a bunch of other shrinks in an old stately house which has been converted into The New Haven Psychiatric Associates. Annie is chatting with a colleague when oops, she suddenly realizes she's late to couples' therapy and she bursts into the session to find her shrink husband banging the shrink couples' therapist, and it's down hill from there. This show is trying oh so hard to be something, the high point being when Annie runs down Eric with her car. I'll spare you the plot line of the disturbed adopted Russian kid who runs away from his uptight American family to sleep at the foot of his child psychologist's bed. It doesn't help that the psychologist doesn't try very hard to dissuade anyone from thinking he's a pedophile. Have I told you how much I miss Dr. Melfi?

With that an introduction, we have a guest blogger joining us today. Dr. Mark Komrad of Sheppard Pratt Hospital joins us for a post and asked if we'd reprint a piece he wrote for the MPS newsletter. Without further ado:

You have 20 years of clinical experience under your belt. You feel that you know your strengths, weaknesses, and limits. You've come to believe that the therapeutic relationship is the key "medically active ingredient" in treatment. So, you start to think that it is the most important thing to develop, enhance and preserve in your work with patients. You are treating a new patient who believes that much can be learned from you; not just your knowledge but the way you live your life. You respond. You share stories about your life: your marriage, your struggles parenting your child, your experiences in college. The patient really resonates. This encourages you to start sharing more vulnerable stories--episodes that have much in common with the patient's experience. You find yourself sharing how a professor in college crossed some lines with you, got too close, actually seduced you. The patient feels your pain, because its similar. Next session, you get a gift form the patient. It's food. The patient invites you to share the food. You need no further reflection, after 20 years, than to check in with your own feelings. It feels right. Develop the relationship, don't allow the patient to feel rejection. You prepare your coffee table to share the repast. The next session, is a beautiful day, you move out to the balcony together and share food again. Feels right. Next session, another gorgeous day, and the park across the street seems like an inviting therapeutic environment. So you move the session out there, its like having a class outdoors on a beautiful day in college--no harm done.

The following session, you get up in the morning, see the weather is fine again, know that its a hot day, so that morning you dress in something more comfortable and casual for outdoors. It's slightly more revealing, but it feels comfortable, and that's important. Towards the end of that session, after eating, coffee feels right, so you and the patient swing by the cafe for a cup. The therapeutic relationship is deepening, the patient is trusting you more and more. You're getting to material than has never been reached before. You are feeling very effective, the sensation of a senior therapist, at ease in your complex art. You find yourself looking forward to these sessions. In fact, you start to make sure that there is nobody else scheduled immediately after this patient's hour, so you can linger a bit longer over coffee. It helps to move the session to the last one of the day. You are increasingly aware that you are treating a truly remarkable person, and feel fortunate for the serendipity of being matched up by referral and chance. Indeed, you feel that your years of experience permit you to try stretching, taking slight extensions of conventional technique--bending technical rules that are really designed more for beginners, to help structure their introductory years in the ill-defined and elusively broad art of therapy. Like training wheels, you sense there is a point where typical conventions are oversimplified and even unnecessary. This isn't something you can or even need to talk about with any colleague. They probably wouldn't understand. They have to be here, in this particular therapeutic relationship, to really get it. Only you can get it. It took 20 years, but you're really feeling you are starting to get it.

And so it goes: the slow procession of feelings, rationalizations, and instincts which propel you down a self-determined, well meaning, and increasingly self-deluded path. You drift further and further "off-the-reservation," a satisfying journey which, one day, ends in surprise, when you are being interviewed by the Maryland Board of Physicians about this case. Where did you go wrong? Did you ever know you had?

For the last few years, as Chairman of the Clinical Ethics Committee for Sheppard Pratt Health Systems, I have been called upon widely to give lectures on topics in Medical Ethics, with a specific focus on ethical issues in mental health care. The audiences are almost always social workers and psychologists; rarely, if ever, is there a psychiatrist in the audience. Why is this? It turns out that for some years, both of these professions have required not just continuing education credits to renew their licenses to practice, but specifically, 3 credits yearly in ethics. In contrast to our fellow mental health professionals, though we are required to have yearly credits to renew our licenses as physicians, there are no specific requirements for psychiatrists to take courses in any particular area, let alone ethics.

I want to argue that a requirement in ethics training for physicians in general, psychiatrists in particular, should be implemented, in parallel with the already established requirements of social workers and psychologists. Historically, physicians were long resistant to the idea of medical ethics as an important clinical discipline. There was a sense that it belonged as a course in philosophy departments or at special “think tanks” like the Hastings Center for Bioethics in New York, but not in hospitals, on rounds, or in grand rounds. However, that recalcitrance was gradually eroded, partly with the help of the Joint Commission on Accreditation of Health care Organizations (JCAHO) which, over the last decade, has started to require that hospitals have an Ethics Committee, which could be consulted by staff or patients. Even prior to this, the federal government instituted the requirement of an Institutional Review Board (IRB) to review any protocol for human experimentation for ethical soundness.

One need not look past the headlines to observe that we live in times of great ethical confusion and misbehavior in many professions. My own work with ethics consultations in health care systems and on the MPS Peer Review committee has revealed to me that there is indeed considerable ethical confusion and misadventure (both knowingly and unknowingly) among psychiatrists.

Systematic ways of thinking through moral conundrums do exist and have been developed in the formal field of Medical Ethics. These processes are not necessarily merely a matter of following one’s intuition. Indeed, I have seen “clinical intuition” lead many a psychiatrist astray in this domain. The ever increasing pressure to make decisions quickly, to spend less time with patients and less time in consultation with colleagues, have all combined to increase the chance of clinical behavior that is not just substandard, but frankly, unethical.

It turns out that considerable thought, writing, and discussion has been taking place in the field of Medical Ethics over the last few decades, which is keeping up with developments. Issues that have challenged ethical thinking are evolving. Such issues as the ethics of relating to managed care organizations, doctor/patient boundaries, and patients refusing treatment are just examples of issues about which thinking has been rapidly evolving in systematic ethical analysis. Critical thinking about these areas is advancing, much as neuroscience and pharmacology are advancing. Yet there is little opportunity to avail oneself of training in these matters. Indeed, the demands of more concrete and procedural knowledge, such as psychopharmacology, can be seductive and can lead one away from the “softer” topics when considering how to spend precious CME hours.

Moreover, there are not many CME hours out there for ethical training of psychiatrists. I recently had an opportunity to give an hour lecture on a CME closed-circuit TV and webcast program. Though asked for more, it was impossible for the producers to find underwriters for more ethics broadcasts. In contrast, underwriters (read: pharmaceutical companies) were standing in line to sponsor programs on treatments of illnesses with pharmacotherapy.

The fact is that mandating continuing education in ethics for social work and psychology produced a market for such courses, and suddenly, they were commonly available. In my experience, they are eagerly attended, not simply because they are mandated. Attendees seem to find this training of immediate value to common practice conundrums. These seminars actually help to raise basic awareness of when one is actually on ethically controversial ground-- a basic awareness that, though fundamental, is often lacking. It is one thing to know how to skate on thin ice; it is another thing entirely to learn how to recognize that the ice is getting thin.

More than any other kinds of healing professionals, therapists and psychiatrists are often soloists. What we do is, by necessity, very private. Typically, we are utterly alone with our patients. This makes us vulnerable to creating a hermetically sealed zone in which our clinical judgment is deployed, without being readily accessible to feedback from other authoritative colleagues or sources. My work on the MPS Peer Review Committee demonstrates to me the kind of “judgement trance” that can be fostered, in which progressive rationalizations can lead to a subtle, gradual drift away from standard ethical practice. Unfortunately, it is often left to the patient or family member to ring the alarm bell, signaling that the psychiatrist is “off-the-reservation.” One need only read the report of sanctions by the Maryland Board of Physicians to see that psychiatrists are overly-represented in that roll call of dishonor.

I submit that this is not surprising, considering the nature of our work. That means that our specialty has a particular need for ethical education to cultivate a more robust and effective ethical self-monitoring.

This is the reason that I think it is time for us to join the good sense of our colleagues, the social workers and psychologists, and require of ourselves mandatory continuing education in one particular area -- ethics. The zeitgeist of our increasingly ethically confused society calls for it, the virtue of humility in the face of a complex clinical art calls for it, and last (and least)-- our malpractice attorneys call for it.

Sunday, July 22, 2007

This time we recorded inside Clink's place, away from the buses and the birds and the helicoptors. I also did not use the GarageBand filter ("Female Radio") which I usually use to filter out low-volume background noises during silent periods. Let me know your thoughts about how it sounds. We are *thinking* about maybe getting lapel mikes and an inexpensive little mixer to balance out our voices better (any suggestions on products welcomed).

Also, we recorded this last weekend. Since it is a shrink rule that we must take off in August (I swear, they'll kick you out of the APA if you don't), we prerecorded two more podcasts (actually, more like one-and-a-half) which I will dribble out over the next few weeks, but we will return with fresh bloviating blather towards the end of August. (Can't wait? Listen to some old My Three Shrinks.)July 22, 2007: #29 Suicidal Breast Implants

Topics include:

Brief discussion about iTunes. We hit #6 in the Medicine section in iTunes last week, thanks in part to KevinMD blogging about our last podcast. We are now getting about 8-9000 podcast downloads per month, which we all find rather amazing. Of course, after the U.S., the country we get the most hits from is China, so we figure there must be Chinese people somewhere trying to learn English from us (big mistake). For the handful of psychiatrists out there (Chinese or otherwise), perhaps we'll release one of those Dummies books about how to make podcasts.

You're Supposed to Get Better. Dinah's post about how to know when you are making progress in therapy, and when to move on. (On the blog, this led to a series of emotional posts and comments about therapy, the power inequity between therapist and patient, and the differences between docs blogging about pts and vice versa. Go here, here, and there to read more.)

Cosmetic Breast Augmentation and Suicide. Dinah reviews this article from the July issue of AJP, from David B. Sarwer, et al., which finds "Across the six studies, the suicide rate of women whoreceived cosmetic breast implants is approximately twice theexpected rate based on estimates of the general population." I guess we need a black box warning on silicone breast implants now. (We had a post a year ago about the Good Breast; this one is obviously the Bad Breast.)

Q&A: "Is chronic antidepressant use harmful in the long term?" We don't really do this topic justice, but Dinah refers to a prior post here.

Coming up on the next podcast: 3 AJP articles on suicide and depression treatment; federal parity laws; managing agitated patients in your office.

I haven't been able to get this song out of my head for the last 2 weeks (prompting me to get the song from iTunes and then buy the CD), so I thought I'd share the infection with everyone: Mr. Blue Sky by Electric Light Orchestra (ELO). For a really cute video of this song, check out CurlyLisa's gang on YouTube.

Saturday, July 21, 2007

Over the last two weeks, ClinkShrink and I have written a series of posts about the flow of information between therapist and patient, and the flow of information between those parties and their blog readers! Let Me Tell You About Myself looks at the issue of therapists divulging to patients that they themselves have a mental illness. Let Me Tell You About My Patientwent on to talk about confidentiality issues in therapy when the psychiatrist has a blog, and Let Me Tell You About My Doctor asks whether it's okay for a patient to write blog posts about their physicians. These posts received a lot of comments, discussion, and brought up a lot of feelings on the part of the both our readers and we three bloggers.

Let me tell you that while I love to stir things up a little, I've been surprised.

To be clear: I can only recall a few posts of our now 506 (yup) posts where I discussed a patient scenario-- the descriptions, the demographics and the issues at hand were all confabulated to the point of fiction and the patients were not recognizable, they are essentially literary Avatars. The posts were about me and my feelings. Of the few (maybe 2-3) posts where I've painted a scenario, the possibility arises that patient could visit the blog and say, "Hey, here's my doc, and I'm a criminal, and she wrote a post about being uncomfortable about treating someone who's a criminal (See: The Patient As Criminal) but I don't drive a Porsche, or wear a Rolex watch, or have 3 kids, or even own a blue suit." The "patient" might have some discomfort learning that I'm uncomfortable (hmmm, Tony seems to know Dr. Melfi was pretty ill at ease).

The truth is, I feel a twinge whenever I so much as mention the existence of a patient. A what if scenario.... so remember my post about my chaotic day where I told a patient (no details about patient at all) that I'd return her call but I then threw my cell phone, with her phone number, into my washing machine? I wondered, what if this patient told all her friends, "I called this ditzy shrink who lost my number in her submerged cell phone," and then her friends saw my post, they'd know who her doc was! Funny, but I don't worry about what if she runs into a friend in my waiting room, who then knows who her shrink is.

I guess the real issue here is one of discomfort, my own and yours, and the theoretical discomfort of any patients who stumble across this. Readers have made comments discussing how they wouldn't like their psychiatrists to have a blog, how they'd worry about their confidentiality, and how it might be uncomfortable to know their psychiatrist in the way that Clink, Roy, and I have let ourselves be known on Shrink Rap. Mine is a more intimate and playful voice than I use with patients. Clearly I might be a little uncomfortable sharing this world depending on my patient's response, and truly I hope I don't make my patients uneasy.

I think the bigger issue is one of Who we Hope our Docs will be outside the office and how much a professional is obligated to live their personal life to a set of fantasized standards-- we'd all like to think our physicians are upstanding, totally moral, law-abiding, healthy-living, paragons of practice-what-they-preach and the existence of a blog threatens that fantasy. It's just docs and shrinks, it's all the folks we see as taking care of us from our yoga instructor to our elected officials and many of us have feelings about what our presidents do with their cigars.

There is no issue at Shrink Rap about ethical violations, power struggles, damages, breach of trust, or lawsuits-- things that came up in our comment section. It's all about comfort and discomfort, I saw the issue as being smaller than the discussion grew it to. This is not to scold, it's just to express my surprise.

Finally, my thoughts about patients blogging about their docs. If the doc is written about in a derogatory way with any possible identifying information, then I think there are better ways of complaining about a doc. If you're writing about your sessions, if your blog post is therapy for your therapy (!), and your shrink is identifiable, I guess I think you should let that be known to the doc. I don't believe that because someone has a psychiatric disorder, anything they say is immedicately discounted. I just don't. Mostly, it's about human courtesy and mutual respect. We're still all just figuring out the rules here.

Friday, July 20, 2007

Okay, this is a new one on me. USA Today has a story on placentophagy, which is believed by some to help prevent postpartum depression.

"French's midwife offered her an unusual remedy: She suggested the expectant mother ingest her own placenta as a means of allaying postpartum depression. The temporary organ was saved, dried and emulsified, then placed in gelatin capsules and taken by the mother in the months after the birth in December 2004.

'Before I actually did it, my friends thought it was weird,' says French, 29, of Spokane, Wash., whose fifth child is due in August. 'But when they saw how fast I recovered from my birth and they knew my history, they thought it was pretty neat. Now I have a lot of friends planning to do it.' "

An expert quoted in the article noted the absence of evidence that this practice is effective.

A well-known psychiatrist in Langley, Virginia, suggests eating it "fried with liver and onions and a nice Chianti."

Tuesday, July 17, 2007

The enclosed claims were received in our mailroom and are being returned because the incorrect claim form was used. Claims must be submitted on the CMS 1500 (08/) version of the CMS 1500 claim form printed with red "dropout" ink for the forms to be scanned into Medicare's computer system.

Newsletter 100-20 CR51 published May 2, 2007 outlines the effective date for submission of the new CMS 1500 claim form as July 2, 2007.

Thank you for your cooperation.

Sincerely,

Claims RepresentativeMedicare Part B

And so I'm left to ask:Anyone want to buy a few hundred CMS 1500 (12/90) forms? And could you lend me just a little "dropout" ink?

Wow, Dinah brought up a great topic. She said: "So how come it's okay for patients to blog about their psychiatrists, without disguise, without permission, without hesitation?"

I just had to address this because this one-sidedness (if that's a word) is something I see in the correctional world. Here's how it happens:

Inmate X gets released and goes to the media. He/she alleges that the correctional facility, as well as correctional physician or nurses, are horrible incompetent sadistic people who provided terrible care. Inmate X is quoted in the newspaper along with detailed allegations of how he/she was mistreated. Because of healthcare privacy laws, the news media cannot be given factual information from the medical record which directly contradicts the inmate's claims. The article states only that 'the facility/administrator declined to provide information about inmate X citing medical confidentiality'. Thus, it appears that someone is covering up something.

Let me be clear that I have never personally been involved in one of these scenarios, but from my professional colleagues I can tell you that it happens. Patients are allowed to reveal their own information, but we cannot do the same without their permission. Over the course of time I've seen some pretty astounding self-revelations: former patients who have gone on TV talk shows to talk about their crimes and subsequent psychiatric care, patients who have had their offenses turned into made-for-TV movies and television episodes, and patients who have written books about their issues. (I made a cameo appearance in one book but was not mistaken for a nun. The author did not seek my permission.) To my knowledge there is no case law to suggest that this behavior constitutes any kind of de facto waiver of confidentiality.

Now we come to the blogosphere. Here, the landscape may be very different. The blogosphere is a public forum of the nth magnitude. There are numerous cases here in the US in which bloggers, and even their service providers, have been found liable for libel or defamation. I refer you to the Internet Journalist for a very nice little overview of case law surrounding invasion of privacy and defamation on the Internet.

So to get back to Dinah's point, it may really NOT be OK for patients to blog in a negative and undisguised fashion about their mental health providers. The real question is: how do you decide what to do about it? It's a situation similar to the one I discussed in Fully Charged Battery, where I talked about filing criminal charges against patients. If they're still your patient, you will certainly damage what little alliance you may have left by filing a libel suit against them. You could bring it up as a therapeutic issue within session, but then you've created a situation where the patient knows you've read their blog and there are things going on outside the session. Or you could decide that a patient who posts negative information about you is simply someone you don't want to continue treating. Regardless, it's a nasty situation. Patient who blog about their doctors/therapists may do well to consider the same precautions that health care bloggers follow.

Monday, July 16, 2007

There's a story I've been wanting to tell you. I've been waiting, trying to give it some distance from the real-life tale, figuring I'd get to it. I've been writing it in my head, thinking of ways to manipulate the story to get it to reflect my emotions and my experience while disguising the real story.

I always feel a bit ill at ease when I write about my experiences with patients, and with this, our 502nd Shrink Rap post, I've only written about "real life" tales a couple of times. I wrote once about a patient who was a criminal, and trust me, my patient would not have recognized himself (at least not by description), all that rang true from that post was the following: I have a patient in some illegal means of obtaining money and knowing this makes me uncomfortable. I could have just written that sentence, purged myself of the feeling for the day, but the story you'd like to read is in the character, real or fictionalized, who gets us to that point. I've wanted to write a post about Resilience and to say, without a vignette, that some people are pretty resilient-- well, it's pretty hollow. I'll point out that my pseudonymous co-bloggersClinkShrink and Roy pretty much never talk about patient encounters, except when Clink quotes her patients as saying she walks like a psychiatrist (she does).

So why the fuss? I've been thinking about my post for a little bit, feeling ill at ease with the patient part of it-- yes, the patient will be fictionalized but my response to the tale is not: if this particular patient read the very-confabulated story on the blog, he might say, "Hey, you said that to me!" Is that wrong? A lot would be assumed here: 1) That someone actually listens to what I say and 2) That I don't say the same things to lots of patients ...umm, actually I reuse lines a lot-- the human condition bears lots of similarities amongst it's members and if I can find something to say that resonates or offers comfort, you bet I'm recycling it, and 3) That it would trouble a patient if I talked about what amounts to my "Isn't that interesting?" feeling about someone's session or condition.

And so as I was about to post about Resilience, I came upon Ad Libitum's post on blogging about patients: It violates confidentiality, it can erode trust, the physician becomes distracted by his never-ending search for bloggable stories, the patient really owns the story and when the blog gets turned into a book/movie, the patient does not share in the royalties (huh? If only...). Ad Libitum says we should obtain consent from the patient, make the patient unrecognizable or an amalgam, and best of all we should not blog about patients. There are a lot of rules here, and these folks are blogging anonymously.

Then came Grunt Doc who calls Ad Libitum "a professional scold." It's okay, he says, to blog about patients who are sufficiently disguised, stories are shared, and so little of our lives are blog worthy that we won't be distracted anyway.

So how come it's okay for patients to blog about their psychiatrists, without disguise, without permission, without hesitation?

Interesting stuff to think about. I think I'll hold off on that Resilience tale for yet another day.

The July 2007 issue of the American Journal of Psychiatry has a lot of good stuff in it this month, including this tribute to Syd Barrett of Pink Floyd, who died last year.

Roger Keith "Syd" Barrett (1946–2006)by Paolo Fusar-Poli, M.D.

Roger Keith "Syd" Barrett was both the founding member of one of the most legendary rock bands and probably the most famous rock star to develop psychosis. He formed the band that would become Pink Floyd in 1965, amalgamating the first names of two American bluesmen, Pink Anderson and Floyd Council.

Recorded at Abbey Road Studios, inspired by LSD (1), and driven by Barrett’s songwriting, singing, and otherworldly guitar solos, the first album, "The Piper at the Gates of Dawn" (1967), alchemized the whimsical bohemian spirit of the "summer of love" and influenced generations of musicians with its sonic inventions and surreal lyrics. Music journalists have called him "the golden boy of the mind-melting late-60s psychedelic era, its brightest star and ultimately its most tragic victim" (2). In fact after two haunting solo albums, "The Madcap Laughs" [history] and "Barrett," which showed the last flickering lights of his genius, his eccentric and creative personality drifted into a psychotic reclusive state, forcing him to withdraw from public view in 1974 (3–5). However, Pink Floyd would pay tribute to Barrett and would include madness as an ongoing theme on their best and most successful albums, "Dark Side of the Moon" (1973) and "The Wall" (1979), speaking to Syd directly in the songs "Wish You Were Here" and "Shine on You Crazy Diamond."

Barrett spent the rest of his life in his mother’s house in Cambridge, painting and gardening.

SPEECH OF HON. FORTNEY PETE STARK OF CALIFORNIA IN THE HOUSE OF REPRESENTATIVES FRIDAY, MARCH 23, 2007

Mr. STARK. Madam Speaker, I rise today with my colleagues JIM RAMSTAD of Minnesota and PATRICK KENNEDY from Rhode Island to introduce the Medicare Mental Health Modernization Act, a bill to provide mental health parity in Medicare. I have introduced a version of this bill in every Congress since 1994. Perhaps this time we can actually enact it.

Medicare's mental health benefit is fashioned on treatments provided in 1965, but mental health care has changed dramatically over the last 42 years. Medicare limits inpatient coverage at psychiatric hospitals to 190 days over an individual's lifetime. In addition, beneficiaries are charged a discriminatory 50 percent coinsurance for outpatient psychotherapy services, compared to 20 percent for physical health services.

This bill is long overdue. One in five members of our senior population displays mental difficulties that are not part of the normal aging process. In primary care settings, more than a third of senior citizens demonstrate symptoms of depression and impaired social functioning. Yet only one out of every three mentally ill seniors receives the mental health services he/she needs. Older adults also have one of the highest rates of suicide of any segment of our population. In addition, mental illness is the single largest diagnostic category for Medicare beneficiaries who qualify as disabled.

There is a critical need for effective and accessible mental health care for our Medicare population. Recent research has found a direct relationship between treating depression in older adults and improved physical functioning associated with independent living. Unfortunately, the current structure of Medicare mental health benefits is inadequate and presents multiple barriers to access of essential treatment. This bill addresses these problems.

It reduces the discriminatory co-payment for outpatient mental health services from 50 percent to the 20 percent level charged for most other Part B medical services.

It eliminates the arbitrary 190-day lifetime cap on inpatient services in psychiatric hospitals.

It improves beneficiary access to mental health services by including within Medicare a number of community-based residential and intensive outpatient mental health services that characterize today's state-of-the-art clinical practices.

It further improves access to needed mental health services by addressing the shortage of qualified mental health professionals serving older and disabled Americans in rural and other medically underserved areas by allowing state licensed marriage and family therapists and mental health counselors to provide Medicare-covered services.

Similarly, it corrects a legislative oversight that will facilitate the provision of mental health services by clinical social workers within skilled nursing facilities.

It requires the Secretary of Health and Human Services to conduct a study to examine whether the Medicare criteria to cover therapeutic services to beneficiaries with Alzheimer's and related cognitive disorders discriminates by being too restrictive.

In April 2002, President Bush identified unfair treatment limitations placed on mental health benefits as a major barrier to mental health care and urged Congress to enact legislation that would provide full parity in the health insurance coverage of mental and physical illnesses. We've made important strides forward for the under-65 population. Twenty-six states have enacted full mental health parity. The Federal Employees Health Benefits Plan (FEHBP) was improved in 2001 to assure that all federal employees and members of Congress are provided parity for mental health and substance abuse treatment. This month, Representatives KENNEDY and RAMSTAD introduced H.R. 1424 , the Paul Wellstone Mental Health and Addiction Equity Act, to provide full parity for mental health and substance abuse in the private insurance market nationwide.

I'm proud to join them in support of this legislation, which was introduced with 256 cosponsors--well more than the 218 majority needed to pass the House of Representatives.

While some in the business community are concerned about increased costs associated with providing these benefits, a recent study of the FEHBP mental health coverage concluded that implementation of parity benefits led to negligible cost increases. In fact, some businesses are now embracing parity because they recognize the increased productivity from workers over the long run and how improving access to mental health services has the potential to avoid other additional costly care.

I am similarly sure that modernizing the Medicare mental health benefit will reduce unnecessary spending. Medicare mental health expenses have historically been heavily skewed toward more expensive inpatient services, with 56 percent of the total going to inpatient care and only 30 percent toward outpatient services in 2001. This relationship is in contrast to national trends showing a reversal in inpatient and outpatient spending over the past decade. In the last 10 years, inpatient spending declined from 40 percent to 24 percent, while outpatient spending increased from 36 percent to 50 percent of all mental health spending. In addition, improving beneficiary access to timely mental health care could well yield savings by minimizing the need for other services.

Science has demonstrated that mental illness and substance abuse are manifestations of biological diseases. It is long past time forus to take action with regard to Medicare's inadequate mental health benefits and structure. Over the years, Congress has updated Medicare's benefits for treatment of physical illnesses as the practice of medicine has changed. The mental health field has undergone many advances over the past several decades. Effective research-validated interventions have been developed for many mental conditions that affect stricken beneficiaries. Most mental conditions no longer require long-term hospitalizations, and can be effectively treated in less restrictive community settings. This bill recognizes these advances in clinical treatment practices and adjusts Medicare's mental health coverage to account for them.

The Medicare Mental Health Modernization Act removes discriminatory features from the Medicare mental health benefits while facilitating access to up-to-date and affordable mental health services for our senior citizens and people with disabilities. I urge my colleagues to join Mr. RAMSTAD, Mr. KENNEDY, and myself in support of this important legislation and to work with us to improve mental health coverage for everyone.

Thursday, July 12, 2007

Sorry for the sound quality again this week. We were outside, and I really did put the mic closer to Clink and Dinah than to me. We'll try something a little different next time.

July 9, 2007: #28 Can You Hear Me Now?

Topics include:

Panetti v. Quarterman. Clink talks about a hot-off-the-press, landmark Supreme Court case about competency to be executed and death penalty cases for people with mental illness. She also refers to the Ford v. Wainwright case. "It's a hint that, down the road, we will probably not have a death penalty for mentally ill people, just like we no longer have a death penalty for juveniles or mentally retarded people."

Dinah goes back to Podcast #27 and refers to Dr. Kay Redfield Jamison's book, An Unquiet Mind, talking about therapists' disclosure to patients about their own mental health issues (which was blogged about here).

On Being a Female Intern. Clink rants against DrCrippen's (NHS Blog Doctor) rant about part-time doctors (mostly mothers): DrC: "You need to grow up a little. You can’t expect to pop into the hospital to do occasional clinics at a time of your own choosing in between school runs, parent-teachers association meetings and back packing holidays. Life is not like that. Being a hospital consultant requires commitment, dedication and long hours. There is generous provision for paid maternity leave. What more do you want? ... If you won’t do the hours, you can’t have job... Just because you are a girlie, you can’t expect medical training to be turned on its head."

Physician Stress & Burnout. This discussion transitions into talk of a 2004 article (IC McManus, et al.) on physician stress and burnout, finding that the consequences of physician training stress has more to do with how one handles stress in general.

iTunes Reviews. Clink asks our listeners to do more reviews of our podcast, and we offer to mention the next 3 reviewers (good or bad) on our next podcast (whoopee!).

Sex Change Operations in Prison?. Clink talks about a recent case of many thousands of dollars being spent litigating a case of a prisoner requesting a sex change operation.

Pristiq. Desvenlafaxine (a metabolite of Effexor or venlafaxine) is up for final approval at the FDA (I misspoke in the podcast... Pristiq is not an extended release of Effexor, but rather a metabolite of it).

Wednesday, July 11, 2007

If one is comfortable with their therapist and feels the therapist seems to know what they are doing, how much lack of improvement should one tolerate before deciding it's time for a change? I know it's impossible to talk about an exact time frame given different diagnoses and personalities and treatment progress, etc etc, but is there any indication?And if so, what should one do? Bring it up with one's therapist and see what happens, switch therapists, get a second opinion? ...I was in a situation where I made no progress after 40 sessions and 3 drugs, had no experience with other therapists, and didn't think the therapy was going anywhere, but my therapist seemed competent.

Wow, where do I begin? Our questioner uses the term "therapist", and I'm going to substitute "psychiatrist" while I think about this because I'm simply not qualified to answer this from the point of view of another mental health professional. For the sake of this particular question, the fact that I prescribe medications makes, I believe, a huge difference in both who seeks my services and how I view outcome. Oh, and if no one minds, I want to talk about this in a vacuum, free from the discussion of insurance, reimbursement, "medical necessity", and who deserves care.

People come to psychiatric treatment for a variety of reasons, but most commonly because they are having a constellation of symptoms which someone (the patient, a family member, their primary care physician) has identified as being indicative of a mental illness. In plain English: people come to see me because they're feeling badly or acting weirdly. The patient comes with, for example, a complaint of sadness, changes in sleep and/or appetite, hopelessness, decreased energy, thoughts of death or suicide, decreased interest and activity.

A second reason people seek treatment is because they have experienced an overwhelming stress and they feel they are not coping with it well: the stress has resulted in either subjective distress, an inability to function normally, or the stress has precipitated a full-blown psychiatric disorder (back to where we started). For the sake of discussion, we can lump these first two groups of people together as patients with specific symptoms they want resolved.

A third common reason for seeking psychiatric treatment is that the patient is unhappy with the course his life has taken and feels he has maladaptive patterns of behaving and/or interacting which interfere with his ability to love or to work to his full potential. Sometimes people in this situation have personality disorders. Generally, people do not seek psychiatric treatment if they are having normal reactions to bad events or if they have no symptoms and believe they didn't get their last promotion because of bad luck or something completely external to them.

Okay, so Patient Number One, with an acute onset of psychiatric disorder, wants his symptoms relieved. Often, medications are prescribed. Psychotherapy focuses on education about illness and support. People in a state of distress often feel an intense and powerful need to understand Why this has happened and want to talk about the precipitants of the episode, or if there are none obvious, their theories as to what may have gone wrong.

There is often a huge sense of relief simply in the telling of the story and the hopefulness of finding help. If the medications work, the patient often wants to end therapy or to come less often. People who are by nature a bit anxious often feel that regular therapy sessions keep them grounded and prevents recurrence. I don't know that they're right ( studies on Maintenance Psychotherapy, anyone?), however in those with repeated episodes of illness, if they are seen frequently it is easier to catch an episode and intervene early, and the patients who want to continue coming between episodes feel greatly comforted by psychotherapy for reasons that are sometimes difficult to articulate. One patient described therapy as a "safety net", and that's about as good as I've been able to get.

Let's move on to Patient Number Two: the person who is stuck in a bad place and thinks they should be getting more out of life. Sometimes people come to see me with a very specific concern: "I want to work on X" -- oh gosh, maybe feelings about a bad childhood, distress about a romantic relationship gone or going bad. These patients often talk for a few sessions, feel helped, and finish therapy quickly.

What about the patient with a personality disorder who repeatedly foils themselves or views life in a self-defeating way? These patients typically find me because they have a co-existing Axis I disorder -- meaning depression or anxiety or bipolar disorder, as in the last paragraph. But when their symptoms resolve with medications, their problems don't. These patients often continue with psychotherapy for a long time, and the therapy itself (and the therapist!) grow to have meaning above and beyond the issue of Fix the Problem, Doc. The end point becomes foggier, the treatment is more of a process, the goals may be clearly defined, but perhaps unattainable. And the treatment may start with the idea that progress will be slow and even painful. The relationship with the therapist may itself become a focus of attention, and this all gets muddled with what is going on with the illness and the meds and things are often just not so clear. Sometimes, it's not all that obvious exactly what is being worked on in psychotherapy and then, for lack of something that better describes what we do, therapy is deemed a "holding environment." I hate that term, and I like to know we're moving towards something, but that's just not always the case.

So How Long?

For someone seeing a psychiatrist with a psychiatric disorder, medications often provide relief. Medications take different amounts of time, not only to work, but to even tell if they are working. Typically, we say that antidepressants (just to use an example) take 3 to 6 weeks to work and they have to be given at high enough doses. If there is no improvement at all in a month, most psychiatrists will raise the dose or switch the medication. If there is partial response (some of the symptoms either resolved or lessened) then another medication -- an augmenting agent -- may be added. Sometimes it takes trying a bunch of medicines in a bunch of combinations, before results are seen, and this can take a while. If I start talking about antimanic agents and antipsychotics, we'll all be here for a while. As long as the patient is symptomatic and suffering, I believe this should be an active and aggressive process. Sometimes nothing works and all that's to be had for all the efforts are a lot of side effects.

For someone seeing a psychiatrist for an issue of dissatisfaction with their life, then it makes sense to stop and evaluate every few months. Are things getting better? Is there another way to go at the problem or something more or different that can be done? If the answer is repeatedly No Change at All, then it's reasonable to get another opinion or try something completely different.

Sometimes it's all very hard to quantify: even patients who don't get better, who continue to suffer or feel stuck, will identify therapy and the therapist as being helpful. Maybe they should get a second opinion, and often they don't want to.

I talk a lot. Please don't count my words. And don't forget to tell us who you are on our sidebar.

Monday, July 09, 2007

After our last podcast, Shrinks on the Take (now what does that even mean?), we received the following comment/questions.

Can one of you comment on this?OCD can make you feel like a weirdo and so I hid it through most of my treatment b/c it wasn’t to bad, even though I didn’t expect my therapist to judge me for it. When I finally brought it up I was somewhat shocked when my therapist said she too had it, but insisted it was well under control, except in situations she doesn’t encounter much where she’ll sometimes carry out a mental compulsion. She mentioned I should add paxil to my wellbutrin, and I said I thought I heard about a lot of paxil withdrawal problems, and she said “yeah I went thru that”. She rarely talks about herself. Though I was shocked I felt really relieved and un-selfconscious afterward. I guess even though I know you are trained to not judge, I think ocd is a hard thing to understand unless you have it and have actually felt that repetitive irrational doubt and those maddening urges- but since I knew she knew the feeling- I think it helped a ton. Still what do you think of mental health professionals who admit to their patients a shared mental illness, or what medications they were on? Does it also depend on the illness? (-note from Dinah: I shortened the question a bit)

What a great question. I've been thinking about this one for days.The issue of self-disclosure in psychotherapy has a number of meanings. The uni-directional flow of information is one of the boundaries that differentiates psychotherapy from friendship. Boundaries, as we've noted before, are important for keeping the therapy safe, and more specifically, it's important that the therapy be about the patient and not the other way around. Self-disclosure in psychotherapy gets a particularly hard rap because of psychotherapy's underpinnings in Freudian psychoanalytic theory where the therapist is required to be a "blank slate." In this school of thought, the treatment requires that the patient know little about the therapist, and so to self-disclose isn't just imprudent, it's actually considered to be harmful to the treatment.

And if this isn't a good enough reason for a therapist not to tell a patient about his own psychiatric disorders, perhaps the therapist's desire for privacy is.

Okay, that said, the reality is that no one is a totally blank slate and no one gets complete privacy. Sometimes the only reasonable thing is to tell patients about a medical condition the therapist is coping with. It's hard to hide a pregnancy, and perhaps patients are entitled to know if their therapists are anticipating a prolonged medical leave for any reason. Full details, full disclosure? I suppose that depends on how personal the problem is (Let me tell you about my prostate?) and the therapist's own desire for privacy.

What about in the case where the therapist has a psychiatric disorder, as in the case our reader describes? Our reader makes the point that the therapist does not usually self-disclose, that the therapy is usually about the patient and we might assume that the therapist considered carefully whether to disclose to the patient her own experiences with OCD.

There is nothing inherently wrong, immoral, or illegal about a therapist telling a patient that she suffers from a psychiatric disorder.

If the therapist doesn't mind the loss of privacy and doesn't then use the sessions to talk about her own problems, it's not wrong, but it can be powerful and so there are risks. As in any conversation, whether something said is helpful or harmful is subject to Monday morning quarterbacking and interpretation, and we don't always control how information is taken or used. A patient can have many responses, including the thought that it's troubling to know the therapist has a mental illness or feels burdened by a therapist's problems.

If the patient is distressed by a therapist's self-disclosure, then it was the wrong thing to do.

If the patient is comforted by their shared condition (especially where the therapist can offer hope and a good outcome), and the patient says, as our writer did, "I think it helped a ton," then it was the right thing to do.

And life would be so much easier if we always knew before we opened our mouths what the exact right thing to say is. I'll call when I get there.

I am very pleased to announce the return of one of my favorite correctional psychiatry bloggers:

FooFoo5 is back after a long abscence. His blog, Turn Your Head And Scoff, has chronicled life in prison (as a psychiatrist) quite vividly and eloquently. We at Shrink Rap welcome him back to the blogosphere.

Sunday, July 08, 2007

The history of the vote: Roy wanted to know who reads Shrink Rap and he put up a poll. This was a while ago. In a month, there were 198 votes. I wondered who all the "other" votes were and, 8 days ago, resurrected the poll with multi-vote and write-in options, . Roy, who likes statistics and keeping track of things, wonders why there are already 104 votes. He wants us to place bets on how many Shrink Rap readers will vote in a month. The guesses:

Roy: 246Clink: 186Dinah: 275

We haven't discussed what the prize will be, though presumably the winner needs to be the closet vote that hasn't gone over. Or maybe just the closest? We're not much for rules here at Shrink Rap. No obscenities, that's about it. Lots of Ducks. Maybe the losers could prepare duck for me with my favorite sauce? Note my optimism!

Okay, so Vote on our sidebar, let us know who you are. Help me win Roy's challenge!

Saturday, July 07, 2007

I saw Rob's excellent An Open Letter to Consultants over on Musings of a Distractible Mind (please go over there and read his letter first... my letter attempts to match his "tone" so don't get all offended if it comes off as testy), so I thought it would make sense to write a similar letter, aimed at medical and surgical attendings who request an inpatient consult from the Consultation-Liaison service. I have also rolled into this my thoughts from Intueri's recent post about delirium in surgical patients.

Dear Requesting Physician:

Thank you for asking me to see your patient in the hospital.

While I understand that you had a few extra years of medical or surgical training above me, and certainly have extensive knowledge in your clinical area, I would like to share with you a few important points about our relationship. Understanding these things will help me better care for your patients and will greatly help me get what I need so that I can do a better job with the consultations I receive from you.

You are not a moron. You went to medical school and probably did a psychiatry rotation. When you request a consult, please -- at a minimum -- tell me what your concern is. "Depression." "Confusion." "Overdose." "Suicidal." Even "acting weird" will do. But "psych consult" is not a reason for a psych consult. Please be more specific.

Your patients are not morons. If they are in the hospital for chest pain and you ask me to see them because you think these are panic attacks, tell your patient I am coming. I've gotten really good at smoothing this over with them, but they are usually shocked, surprised, and sometimes even insulted, that a psych consult has been requested without their knowledge. Having to explain why to them (especially if you haven't given me the reason) can make it harder for me to establish a trusting relationship with them, which really helps if they are going to give me useful information. Be straight with them and tell them you want a second opinion or that you want to "cover all the bases."

Contact me. Call me on the phone and speak to me personally about what is going on with your patient. This is immensely helpful as you have clues in your head that do not get written down on paper. You probably won't write down "I think patient's wife and job is stressing him out to the point that he is probably faking this 'abdominal pain' and making himself vomit, because I can't find anything wrong with him so he must not be truly sick," in the chart, but it would really help me to know that is what you are thinking before I spend an hour addressing some other aspect of this patient.

The "Mental Status Exam" section of the H&P is not restricted to only psychiatrists. Anyone can do one. If you expect your patient has a psychiatric problem, it is customary (though, unfortunately, more rare) to perform a mental status exam, however limited. If your patient had respiratory difficulty, I am certain your exam would be more than simply "Lung: resp 24 and labored."

Here's the most important one. Just because your patient has a history of psychiatric illness or is on a psychiatric medication, don't automatically assume that the presenting symptom is due to one of these. Don't stop looking for the cause of their sudden-onset left-sided weakness just because there is a history of schizophrenia.

I promise to do what I can to make your job easier. Please help me in my quest to do what is best for your patients.

A friend of Iraqi psychiatry resident, Saminkie, is pictured here. His name is Saad. But, as Saminkie notes, Saad is one of the few people in Iraq these days who dares to be happy. Hopefully soon, there can be many more happy people there. Some day. Soon.

Friday, July 06, 2007

Contrary to popular myth, it turns out that women and men tend to talk about the same amounts. A soon-to-be-published study described in Science reported that Pennebaker, et al., "equipped 396 college students--210 of them women--for several days with voice recorders that automatically turned on every 12.5 minutes to record for 30 seconds during their waking hours. All words spoken by the wearer were transcribed, counted, and extrapolated to estimate a daily word count."

The results? Average number of words spoken per day: Women: 16,215 . . . Men: 15,669.The difference is not statistically significant.

In the study, the variation ranged from a low of 700 to a high of 47,000 (that one was a man), according to John Grohol's post in PsychCentral.

While the study, which really only applies to college students and not the general population, failed to confirm the widely-held belief that women talk more than men, it did confirm another stereotype:

“Men talk more about technology, work, money. They also use more numbers,” he said. “Women talk more about fashion and about relationships.”

Here is the histogram showing the spread of spoken daily words among the study participants:

Thursday, July 05, 2007

Each week, for what it's worth, I'm emailed a 16-Google Analytic report. I never asked for it and something tells me this was a Roy inspired thing. I kind of like it, though, and I've taken to actually reading through it. There are two states from which we have no readers at all: New Mexico and Wyoming. Most weeks, we seem to have roughly 2,000 unique visitors and over 4,000 page views. I'm not sure they're not all me checking the blog from assorted computers, but hey.

So who are you? Who reads Shrink Rap?

Please, take our poll on the side bar! It's fun, really. We did it once before, but so many people didn't know who they were, or wanted to be more than one thing, and our most popular answer was "Other." Now, you can be it all, check off as many categories as describe you. Write in the Other box. So far we have 6 Others. Who are they? Here goes:

So one third of the other respondents are my two co-bloggers. I assume Roy is the one who thinks he's patient with me, even though I've stopped putting Links in red after he complained it was too jarring. Even after I neither struck him nor screamed at him when he deceived me into believing Dr. Phil was on the phone during our podcast. I've let him repeatedly photograph my feet. Who's being patient with whom? Maybe that can be our next poll. And by the way, co-blooger friends, you could have checked off both "psychiatrist" and "friend of the bloggers" and been described.

So get out and vote! Tell us who you are. It's free, it's easy, it's anonymous-- you can vote without signing in, without registering, without committing to months of vitamins. You can do it if you've gotten here by accident, if you never ever plan to visit again. Your mother can vote. Your uncle can vote. Your psychiatrist can vote. Just go to the top of our sidebar and click!

Here is the letter that the Medicare Mental Health Equity Coalition (MMHEC) sent to Senators John Kerry (D-Mass.) and Olympia Snowe (R-Maine), thanking them for re-introducing this bill, which would end the discriminatory policy of charging copays for outpatient mental health care which are 250% that of copays for non-mental health care. It takes six years to transition under the plan, but it is better than nothing. It is simply amazing that this type of discrimination has remained for as long as it has.

The undersigned organizations of the Medicare Mental Health Equity Coalition, representing patients, health professionals, health care systems and family members, applaud your introduction of the Medicare Mental Health Copayment Equity Act of 2007 (S.1715). Your legislation will eliminate the unfair provision in federal law imposing a 50 percent coinsurance rate for outpatient mental health services under Medicare instead of the usual 20 percent coinsurance for outpatient services. Our coalition supports enactment of legislation like this that will bring payments for mental health care in line with those required for all other Medicare Part B services.

The Medicare program was established to guarantee health care coverage for all older adults and people with disabilities. However, the 50 percent coinsurance for mental health services has proven to be a harmful barrier preventing many Medicare beneficiaries from accessing services they need. Since its enactment in 1965, we have learned that mental health disorders are highly prevalent in the elderly and disabled populations covered by the Medicare program. A landmark report by the Surgeon General on mental illness in 1999 found that 20 percent of the population aged 55 and older experience mental disorders that are not part of what should be considered as normal aging. In addition, a 2006 report by George Washington University found that 59 percent of Medicare beneficiaries with disabilities have a mental illness and 37 percent have a severe mental illness. Tragically, only about half of those experiencing a mental illness receive mental health treatment, due in large part to antiquated and discriminatory health coverage provisions, such as the 50 percent coinsurance rate under Medicare.

There is simply no reason for maintaining a discriminatory barrier to mental health care for America’s seniors and individuals with disabilities, particularly since these populations present a high incidence of mental health concerns.

We greatly appreciate your leadership in addressing this fundamentally unfair Medicare policy for the 44 million Americans that depend on this program.

MMHEC member organizations include the American Association of Geriatric Psychiatry, the American College of Physicians, the American Psychiatric Association, the American Psychological Association, the Association for Behavioral Health and Wellness, the Center for Medicare Advocacy, Inc., the Medicare Rights Center, Mental Health America, the National Alliance on Mental Illness, the National Association of Social Workers, the National Committee to Preserve Social Security and Medicare, the National Council for Community Behavioral Healthcare, Psychologists for Long Term Care, Inc., and the Suicide Prevention Action Network USA.

Please write each of your senators, asking them to co-sponsor this bipartisan bill to end this antiquated, discriminatory policy against people who require mental health treatment.

Tuesday, July 03, 2007

OK, for the record, DINAH TALKS MORE THAN I DO. Really. Ask her husband. Ask the kids. Ask the judge. Ask Max. Heck, Max talks more than I do. (But at least I don't back up to total strangers and expect to get my butt scratched. Max, you are a strange dog.) I happen to know that a lot of listeners have trouble telling our voices apart. Here's a rule of thumb: if you hear talking, it's Dinah.

geek humor, hex codes, computers, programming or Apple computers (now is the time for Zoe Brain to leap to my defense. We lady geeks need to stick together.)

OK, that being said on podcast #28 you will hear me talking the most. Finally. That's because all my three topics coincidentally got put off taping until the second one (we do two at once). Here's hoping this will help with any confusion.